On World TB Day, an expert view on tuberculosis

On the occasion of World Tuberculosis Day today, pulmonologist Dr. Vivek Nangia pens an exclusive article for TheHealthSite shedding light on the prevalence of TB in India, current government policies and the way forward. He is the Head and Director, Pulmonology, Medical ICU and Sleep Disorders at Fortis Flt Lt Rajan Dhall Hospital, Delhi.

Tuberculosis or TB, as it is popularly called, is a global disease with the highest presence in the developing countries. It is an infectious disease most commonly caused by a bacterium called mycobacterium tuberculosis, that has the propensity to invade and affect almost any part of the human body, but predominantly involves the lungs. TB is the ninth leading cause of death worldwide and the leading cause from a single infectious agent, ranking above HIV/AIDS. India accounts for about a quarter of the global TB burden. In 2016, in India, an estimated 28 lakh cases occurred, and 4.5 lakh people died due to TB. Another estimate shows that more than a million cases go ‘missing’ every year either because they are not notified or remain undiagnosed or unaccountably and inadequately diagnosed.

The TB bacteria has natural defences against some drugs and can acquire drug resistance through genetic mutations against others. Multi-drug-resistant tuberculosis (MDR-TB) is a form of TB infection caused by bacteria that are resistant to treatment with at least two of the most powerful, first line anti tubercular drugs, rifampicin and Isoniazid. Some forms of TB are also resistant to second line drugs and are then called extensively drug-resistant (XDR) TB. The second line drugs include. Fluoroquinolones and injectables like Aminoglycosides among others. Globally in 2016, WHO estimated that 4.1% of new cases and 19% of previously treated cases of TB were of MDR/ RR (Rifampicin Resistant)-TB. There were an estimated 600,000 incident cases of MDR/RR-TB out of which 490,000 were of MDR TB. Almost half of these cases were in India, China and the Russian Federation. There are an estimated 79,000 multi-drug resistant TB patients among the notified cases of pulmonary TB each year. In 2016, MDR-TB and RR-TB caused approximately 240,000 deaths globally.

Multi drug resistance usually develops if incorrect or inadequate treatments are used, which may be due to use of the wrong medications, inadequate medication, poor quality drugs, not taking medication consistently or for the full treatment period (treatment is required for several months). An individual can also develop MDR TB following exposure to TB bacteria from another person who already has MDR or RR-TB. Treatment of a patient with MDR TB is very complex and challenging. It involves taking larger number of drugs (including an injectable for 6-9 months), for a much longer period of time (up to 24 months). These drugs not only are costlier but also have higher incidence of side effects and can be difficult to tolerate for some patients. The latest data from World Health Organization (WHO) shows a treatment success rate for MDR-TB of only 54% for patients starting treatment in 2014.

India is also the country with the second highest number (after South Africa) of estimated HIV associated TB cases. TB is one condition for which the cliché statement “Prevention is better than cure” holds true the most. The most important step towards prevention of TB is to stop its spread by early detection/diagnosis and prompt treatment. For systematic control and management of TB at a national level, the national tuberculosis programme of India (NTP) was initiated way back in 1962. Originally, it was designed for domiciliary treatment, using self‐administered standard drug regimen. In 1992, the situation of TB and the performance of NTP was reviewed which revealed that the NTP, though technically sound, suffered from managerial weakness, inadequate funding, over‐reliance on X‐ray for diagnosis, frequent interrupted supplies of drugs and low rate of treatment completion. In 1997, Revised TB Control Programme (RNTCP) was launched which formulated and adopted the internationally recommended Directly Observed Short Course (DOTS) strategy as the most systemic and cost‐effective approach to revitalize the TB control programme in India.

The government is now calling for the elimination of TB by 2025, and there is a new National Strategic Plan 2017– 2025 with ambitious ideas endorsed by the government. The financial resources for TB control for 2017 – 2025 are to be doubled, the diagnostic tool CB-NAAT is to be rolled out across the country and two new drugs for drug resistant TB (bedaquiline and delamanid) are also to be made more widely available. First and second line drug susceptibility testing is in use or at least on the agenda. Also, patients with TB are tested for HIV and patients with HIV are tested for TB. The private sector is being more actively engaged as a large chunk of patients are treated in private hospitals. It is unprecedented that the Prime Minister has also added his voice to the endorsement.

India now seems to be on the right track towards effective TB control. State-of-the art tools and a strong political leadership are now available to tackle the various challenges. India’s national TB strategic plan for the next four years is in complete alignment with WHO’s End TB Strategy. Achieving universal access to TB care is a key component of India’s campaign for a TB Free India. The newly formed TB research consortium reflects India’s commitment to develop new diagnostics, drugs and vaccines, which are urgently needed to end this epidemic.

Another body, which is playing a major role in strengthening the advocacy for elimination of TB in India, is the Global Coalition against TB (GCAT). The objective of this coalition is to bring together parliamentarians, policy makers and society representatives to discuss the challenges of TB prevention and control in India.

TB is a menace that we, as a nation have been trying to put an end to, since decades. We have achieved a lot in our battle against this deadly disease, but still have a long way to go.

Published: March 24, 2019 9:52 am | Updated:March 24, 2019 9:53 am

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